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OSIP Program Manual

WG.12 Issuing Special Needs Payments for Personal Incidentals and Room and Board

Effective 1/1/12

This worker guide is not policy. It contains guidance and examples for help in understanding the purpose of and correct application of Oregon Administrative Rule 461-155-0700.

For OSIPM clients who need long term care services, it is the Department’s goal to place the client in the least restrictive care setting that is appropriate for the client’s level of care and care setting preference. Therefore, under 461-155-0700 the Department can make special needs payments for personal incidentals/room and board in 4 situations where the client:

• Is leaving a nursing facility or acute care hospital, or is being diverted from a nursing facility, to reside in a community-based care facility, and
• Does not have enough income to pay for personal incidentals and room and board in a community-based care facility, or
• May have enough income for the personal incidentals/room and board, but then does not have enough remaining to pay the community spouse’s full income allowance.

Payments cannot be made under this rule for clients receiving services in their own homes. Special needs payments under this rule are issued by Authorization of Cash Payment (SDS 437) using pay reason 13. Issue the payment to the client who is then responsible for paying the total room and board cost to the service provider or diverting income to the community spouse.

In addition, CMS is not programmed to make these payments at this time. Because the payments are made by Special Cash Pay, figures on the 512 will not reflect accurate information. Please send a Notice of Payment Responsibility (SDS 547) to the provider and the client instead of the 512, when the first payment is issued and each time the payment amount changes.

If you are making a partial month payment because the client moves mid-month, use the chart in SPD Worker Guide F-7 to calculate the prorated amount. For example, if the payment amount is $400 and the client moves on August 13, the calculation is $400 X 61.29% (from the chart) = $245.16 prorated payment. Use the first column on the SDS 547 to notify the client and the provider of the prorated payment amount, and use the second column on the form to notify each of them of the first full-month payment amount. Fill out the form only once, using the client’s (or client’s representative) name as the mailing address. Copy the notice that is sent to the client and highlight the “cc: Service Provider” name at the bottom. Put it into an envelope addressed to the provider. This notice is designed to work the same as the 512; each person gets a copy of the same notice but it is sent in envelopes addressed to different people.

Note that in the liability calculation (see 461-160-0620), the client’s personal needs and room and board are the first and second deductions. The next deduction is for the community spouse’s needs. Therefore, due to the order of the deductions required by this rule, no other deductions (e.g., medical costs) are considered when issuing this special needs payment.

Also, clients who receive these payments while they are awaiting receipt of SSI, will most likely receive a lump sum SSI payment at some point in the future. When that SSI lump sum payment is received, it is excluded for 9 months (see 461-145-0510).

Following are examples of how to calculate special needs payments under this rule:

1. Presumptive Medicaid Disability Determination Team (PMDDT) clients.

Many PMDDT clients have little or no income because they have applied for SSI but have not been approved yet. These clients who move out of a nursing facility or are discharged from an acute care hospital to a community-based care setting are eligible for a payment of up to the OSIPM standard ($698.00). The payment amount is reduced by the client’s countable income.

Example 1: Horace is residing in nursing facility and is a PMDDT client with zero income. Horace wants to move to an adult foster home (AFH). Issue Horace a special need payment of $698.00 per month to cover his personal needs and room and board in the AFH until his SSI is approved.

Example 2: Greta is residing in a nursing facility and is a PMDDT client. She receives $400/month income from a trust that her deceased grandmother funded for her. Greta wants to move to a residential care facility (RCF). Calculate Greta’s payment as follows: $698.00 - $400 trust income = $298.00. Issue Greta a special needs payment of $298.00 per month.

• Note: The client is only eligible for these ongoing payments if he or she continues to pursue the SSI application by appealing denials. If the Social Security Administration (SSA) makes a final administrative decision that the client is not eligible for SSI, send timely notice to end the payments.

2. Clients whose social security or veterans benefit income is erroneously reduced in a community-based care setting.

Sometimes when a client moves from a nursing facility or acute care hospital to a community-based care setting the benefit amount erroneously remains at the nursing facility rate for a period of time. These clients are eligible for a payment of up to the OSIPM standard ($698.00). The payment amount is reduced by the client’s countable income.

Example 3: Ivamae is residing in a nursing facility and receives $30 SSI income. After her condition improves, she moves to an assisted living facility (ALF); however, her SSI remains at $30. Issue Ivamae a special need payment of $698.00 - $30 income = $668.00 per month to cover her personal needs and room and board in the ALF until her SSI is increased to the full benefit amount.

Example 4: Kermit is residing in a nursing facility and receives $90 Veterans benefits. After his condition improves, he moves to an AFH; however, his benefits remain at $90. Issue Kermit a special need payment of $698.00 - $90 income = $608.00 until his Veterans benefit is increased to the full benefit amount.

3. Clients who lose their SSI because they have exceeded the time allowed to become a naturalized citizen.

Qualified non-citizens receive SSI for 7 years to allow them to have time to become naturalized citizens. If the non-citizen fails to become a citizen within that time, the SSI ends. These clients who move out of a nursing facility or are discharged from an acute care hospital to a community-based care setting are eligible for a payment of up to the OSIPM standard ($698.00). The payment amount is reduced by the client’s countable income. The calculation is the same as for PMDDT clients above.

• Note: The client is only eligible for these ongoing payments if he or she continues to pursue becoming a citizen. Send a timely notice to end the benefits if the client fails, without good cause, to take necessary steps to become a citizen. A client who is not competent, for example, would have good cause for failing to pursue naturalization. The Department can authorize a special needs payment to cover the cost of naturalization using the citizenship documentation pay reason (code 30). Continue to authorize the room and board payment until naturalization is obtained and SSI is reinstated.

Liability Worksheet

Recipient Income	Nursing Facility (NF)			Community Based Care (CBC)
Unearned income	$800			$800
Minus appropriate standard	- 30			-675.70
= Adjusted income	$770		$770	$102.00		$102.00
CSIA
Standard from rule		$1839			$1839
Shelter costs	$500			$500
Full Utility Allowance	+395			+395
Total Shelter	$895			$895
Minus Shelter Standard	-552			-552
Excess Shelter	$343	+343		$343	+343
Subtotal needs		$2182			$2182
Minus Spouse’s Income		-1600			-1600
= Calculated CSIA		$582	$582		$582	$582
Spousal Diversion - LDS (lesser of the Adjusted Income or the CSIA)			$582			$102.00
Special Need Payment (NF LDS minus CBC LDS)	$582 (NF) - $102.00 (CBC) = $480.00

Example 6: Mr. W resides in a nursing facility and has $950 SSB income. Mrs. W resides in a home that is paid off, has taxes and insurance costs of $115 + utilities, and has $1,150 countable income.  Mr. W is eligible for a special needs payment of $437.00 to divert him to a community based care setting, as illustrated by the table below.

Liability Worksheet

Recipient Income	Nursing Facility (NF)			Community Based Care (CBC)
Unearned income	$950			$950
Minus appropriate standard	- 30			-698.00
= Adjusted income	$920		$920	$252.00		$252.00
CSIA
Standard from rule		$1839			$1839
Shelter costs	$115			$115
Full Utility Allowance	+395			+395
Total Shelter	$510			$510
Minus Shelter Standard	-552			-552
Excess Shelter	$0	+0		$0	+0
Subtotal needs		$1839			$1839
Minus Spouse’s Income		-1150			-1150
= Calculated CSIA		$689	$689		$689	$689
Spousal Diversion - LDS (lesser of the Adjusted Income or the CSIA)			$689.00			$252.00
Special Need Payment (NF LDS minus CBC LDS)	$689 (NF) -$252.00 (CBC) = $437.00

Example 7: Mr. Y resides in a nursing facility and has $2500 SSB income and an Income Cap Trust. Mrs. Y pays low income rent of $362 and utilities, and has $0 countable income.  Mr. Y is eligible for a special needs payment of $292.00 to divert him to a community based care setting, as illustrated by the table below.

Liability Worksheet

Recipient Income	Nursing Facility (NF)			Community Based Care (CBC)
Unearned income	$2500			$2500
Minus appropriate standard	- 30			-698.00
- Trust Admin Costs	-50			-50
= Adjusted income	$2420		$2420	$1752.00		$1752.00
CSIA
Standard from rule		$1839			$1839
Shelter costs	$362			$362
Full Utility Allowance	+395			+395
Total Shelter	$757			$757
Minus Shelter Standard	-552			-552
Excess Shelter	$205	+205		$205	+205
Subtotal needs		$2044			$2044
Minus Spouse’s Income		-0			-0
= Calculated CSIA		$2044	$2044		$2044	$2044
Spousal Diversion - LDS (lesser of the Adjusted Income or the CSIA)			$2044			$1752.00
Special Need Payment (NF LDS minus CBC LDS)	$2044 (NF) - $1752.00 (CBC) = $292.00

 

Example 8: Mr. V resides in a nursing facility and has $650 SSB income. Mrs. V pays low income rent of $0 and utilities, and has $1000 countable income.  Mr. V is eligible for a special needs payment of $668.00 to divert him to a community based care setting, as illustrated by the table and additional calculation below.

Liability Worksheet

Recipient Income	Nursing Facility (NF)			Community Based Care (CBC)
Unearned income	$650			$650
Minus appropriate standard	- 30			-698.00
= Adjusted income	$620		$620	$0		$0
CSIA
Standard from rule		$1839			$1839
Shelter costs	$0			$0
Full Utility Allowance	+395			+395
Total Shelter	$395			$395
Minus Shelter Standard	-552			-552
Excess Shelter	$0	+0		$0	+0
Subtotal needs		$1839			$1839
Minus Spouse’s Income		-1000			-1000
= Calculated CSIA		$839	$839		$839	$839
Spousal Diversion - LDS (lesser of the Adjusted Income or the CSIA)			$620			$0
Special Need Payment (NF LDS minus CBC LDS)	$620 (NF) - $0 (CBC) = $620

Mr. V also has income that is less than the OSIPM standard, so $698.00 - $650 (client’s income) = $48.00 that is added to the $620 LDS calculated above for a total of $668.00 special need payment.

 

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Phone: (503) 945-5811
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